Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 1320-1339)

11 MARCH 2004

MS MELANIE JOHNSON MP, MS IMOGEN SHARP, MS DANILA ARMSTRONG AND DR ADRIENNE CULLUM

  Q1320 Chairman: I think what both David Amess and Paul Burstow were trying to get out of you is on the scale of carrot here, stick there, where are we? I am not entirely clear from your answers exactly where you are at because you are implying more or less that this will all be resolved in the White Paper. We are getting messages, certainly from Tessa Jowell who is ruling out certain steps on advertising bans that are being introduced in other European countries, so in advance of that we get the impression that there is more carrot than stick and I think we need to be aware of what your thoughts are in framing our own recommendations in this inquiry.

  Miss Johnson: I think that balance is something that may be different for different issues, but I am sure you have actually read what Tessa Jowell said and, as you know, the reporting of it in the headlines is not really accurate. Tessa said much more: the voluntary route was one route; there was still the question about the bans. As I said earlier on, the Food Standards Agency board is only today coming forward with its recommendations as a result of the work that it has been doing on the promotion of foods. We want to look at that and study it so it is not something where we can either say carrot or stick or somewhere on a defined point along that spectrum. Again, it may matter what people say to us on different components of the issues that contribute to the problem of obesity and to the possible solution to it, actually where it ought to be positioned along that spectrum. Broadly speaking, a lot of choices are being made by individuals at the end of the day.

  Q1321 Mr Bradley: You just mentioned about the Food in Schools Programme as a pilot. Could you explain a little more how that programme will be evaluated and how you will come to conclusions about its benefits and how you will uses that to expand similar programmes?

  Miss Johnson: In terms of the detail of how it is being evaluated I cannot go through that, but there is an evaluation programme that is in place at the end of the year to look at how that has been working. The pilot is just to give a little more perspective. There are eight different things running in each of eight regions affecting a number of schools—secondary or primary or both—and what they are doing is testing out things from making more drinking water available (as I am sure you will know) to things like healthier vending machines. I think one of the issues out of this is actually how well those changes have contributed to what is going on about food in the school, whether in fact you need to make a whole range of changes in one place, for example, to really influence things, as I think perhaps might seem sensible. We are discussing closely with DfES both the work that is going on on that and other joint cooperation with them on the whole question of food in schools, its role, how schools can contribute and how those issues can be taken forward.

  Q1322 Mr Bradley: How are you actually evaluating the effectiveness of those changes, whether it is water or whether it is fruit? What are you actually doing on the ground to say that this is making a difference?

  Miss Johnson: On something like the free school fruit, for example, we are evaluating that by polling evidence which is actually showing that a quarter of the children who are receiving free school fruit are actually having more fruit at home and half of the families are recognising that fruit and vegetables are more important in their diet than they had previously thought. There is a significant impact there that we are seeing on the free school fruit programme which I think is receiving a lot of acclaim from both health practitioners and the schools themselves. One of the other impacts that is going on and is being seen in a number of schools is improved behaviour as a result of better food or drink intake in schools. That is something which I think is a real benefit and would indicate a clear value not just, as it were, on the obesity side of things, but in terms of the functioning of individuals and their ability to learn.

  Q1323 Mr Bradley: How are you measuring better behaviour, for example?

  Miss Johnson: The schools themselves will anecdotally report some of this. There are some studies being done, for example, of some of the bits of the programme that are working that are being done through some academic institutions looking at evaluating those results, but if you are asking me about the detail of how those evaluations are carried out I would be happy to write to the Committee with a bit more detail on the evaluation process. It is there; we have an evaluation coming up. I am just not an expert on the detail of how it will be done.

  Q1324 Mr Bradley: Putting that in a wider context, we have commissioned work on the health costs and the wider economic costs of obesity as part of this process. Are you gathering that some information together which presumably will form part of the framework of the White Paper?

  Miss Johnson: Sorry, which information?

  Q1325 Mr Bradley: The wider economic costs of obesity, not just the direct health costs. Are you gathering together those wider economic costs to feed into the White Paper that we will see in the summer?

  Miss Johnson: Certainly I think it is a key feature of a lot of the public health work that actually if the public health work was done well—as Wanless demonstrated very clearly—on a fully engaged scenario there is a huge sum to be saved in terms of the cost to the Health Service and the cost to the nation more widely. The individual sums are being done wherever they can be, is the answer, because I think actually it is a major contributing strand of thought that we actually identify the costs that we are suffering as a result of being more obese or any of the other issues in the main stream of public health areas, and actually work out what the savings are that could be achieved both in terms of money and in terms of quality and length of life, and that we demonstrate those wherever possible. I think Wanless has given a very clear steer on this, that actually if we get fully engaged there is a lot more to be gained than we currently have on a solid progress basis, which is where he would mark us at the moment.

  Q1326 Mr Burns: When was the free fruit policy introduced and started to be operational in schools? What proportion of school children actually receive it at the moment?

  Miss Johnson: About half are currently receiving it; something over a million. It started a couple of years ago. I do not have the exact date but I can no doubt give it to you in a second. By the end of this year all children of infant school age in England will be receiving a free piece of school fruit.

  Q1327 Mr Burns: When you say year, do you mean school year or calendar year?

  Miss Johnson: Where it overlaps with nursery classes I think they are starting, but basically I think we are talking about school years broadly speaking. The National School Fruit Scheme was introduced in 2001.

  Q1328 John Austin: I certainly welcome your statement that obesity is at the top of your priorities along with smoking, but in relation to the impact on primary care your Department has suggested that the targets within the National Service Framework for coronary heart disease and diabetes in themselves give sufficient priority to obesity. The evidence that we have had from clinicians and managers suggests that that is not so and there has been a strong call for a National Service Framework for obesity as the only means for securing the funding and priority that it deserves. One of our witnesses argued that primary care services were working so hard to meet the other targets within coronary heart disease and diabetes that they do not have either the time or the resources to tackle obesity even though that would bring down the rates of CHD and diabetes.

  Miss Johnson: First of all, National Service Framework for CHD means that you obviously need to focus on obesity. You cannot tackle coronary heart disease without recognising that obesity is a major contributory factor to it. Ditto with diabetes, for example, where there is all the work going on with diabetes. There is a forthcoming framework on children where again clearly this is a major issue in terms of children. The question of exactly how this work is taken forward obviously to some extent supersedes the advent of the White Paper as well and clearly the White Paper will hopefully draw more things together in an overarching way to support the work on obesity than may previously have been envisaged. However, what we are also saying is that the new GMS contract provides a lot more opportunities and where it is being done already very well under existing contract arrangements in GP surgeries clearly a lot of advice is being given out, often nurses are involved in giving that advice. There are 816 exercise referral projects going on around the country with GP surgeries referring people into exercise, whether it is at the local gym or swimming pool or whatever. There are all sorts of different programmes to help tackle the question of obesity. The new contract, with its emphasis on health promotion work, does provide a renewed opportunity at a general practice and primary care level for them to focus more strongly even than they are at the moment on issues like this one.

  Q1329 John Austin: Obviously we would welcome those improvements and I think perhaps we need to monitor how the new contract will actually be delivering the kind of service that we would all like to see. Nevertheless at the moment clinicians and managers are saying to us that resources follow National Service Frameworks and although tackling obesity brings down CHD and diabetes the resources are not there for the preventive work on obesity or, indeed, for treatment, and they are strongly calling for a NSF. You also mentioned children. There is a National Service Framework for children but that barely has any reference to obesity in it.

  Miss Johnson: The final Framework on children has not been published yet.

  Q1330 John Austin: Would you ensure that there is a clear reference to obesity and prevention within the children's NSF?

  Miss Johnson: I am sure that is an issue that will be covered as part of the National Service Framework for children.

  Q1331 John Austin: Do you not think that a separate NSF for obesity is required?

  Miss Johnson: No, is the answer to that. I think it is well represented in the existing National Service Frameworks, in fact. What we need to do as part of the drive to better public health and to tackle the issue of obesity is actually to encourage people to join up the issues that relevantly need to be joined up and to make sure that people do not see things simply in single pots, as it were. Of course we could have a National Service Framework for obesity, but it would have to make substantial reference to all the other National Service Frameworks and I think you can see eventually it may not be a very productive way forward for those who are trying to work and deliver things on the ground. I think it is much more important that we encourage people to see these things in the right context and, for example, we have clear targets and are making huge improvements in bringing down deaths from coronary heart disease and cancer—a 23% reduction in deaths from coronary heart disease and 10% reduction in deaths from cancer—so there is huge progress being made but the Service is still very much focussed on those areas because it has targets and it has frameworks and it has cancer plans. These things are all extremely relevant to the question of tackling obesity. We will not hit the targets in the medium to long term unless we actually tackle the issue of obesity and some of the health inequalities issues and smoking that we have to tackle now. The Service needs to recognise that—as many of them already do—and act on it fully. I think the best way of doing that is by an integrated approach across where people understand how everything fits together, which is what the White Paper will help people to do.

  Q1332 John Austin: I will be the first, Minister, to congratulate the Government on the remarkable success that the Government has had in relation to both coronary heart disease and cancer, although obviously there is much more to be done. If I could just focus on diabetes for a moment, we are a little way behind the United States in terms of the growth of obesity but we are going along the same road. We were told in the United States that one third of the children born in 2002, due to obesity, will be likely to develop Type 2 diabetes. We are seeing for the first time in this country the diagnosis of Type 2 diabetes in young people, a disease which was previously reserved for perhaps people of my age rather than a younger age. Has your Department made any estimate not only of the cost in terms of human misery but the cost to the NHS and to your Department if we do not stem the rising growth in Type 2 diabetes?

  Miss Johnson: First of all, just one or two of the facts and figures on it. It is as you say, broadly speaking the vast majority of people who have diabetes actually have Type 2 diabetes. Much of that can be related to obesity; it is not exclusively related to obesity but it may well be. There has been a very big increase in Type 2 diabetes. The estimate at the moment is that diabetes could increase by as much as 58% over the next 20 years which would be a huge hike and a huge health bill as well. It is part of the work that Wanless has done in looking at the gap between fully engaged and present scenarios which indicates the size of that gap. It does not only look at diabetes, as you are well aware, but it looks more widely. We already have incentivisation at primary care level for GPs through the outcomes and quality and outcomes framework to actually focus much more on the management of patients with diabetes and obviously that is something where we need to get a stronger focus, but where the main objective must be to cut obesity and therefore to cut the rates of diabetes in the future. As to figures—I think you asked for an actual cost—I do not think I have a cost to hand, but if we have one I would be very happy to try to get it to you. Can I just say in terms of the free school fruit programme, the actual pilot started in 2001.

  Q1333 John Austin: Despite those alarming figures and the fact that obesity is at the top of you Public Health Agenda, can you still not be persuaded that there needs to be a separate NSF for obesity?

  Miss Johnson: How it is best to bring these things together is something that we will look at through the White Paper. However, I think—for the reasons that I gave earlier on—superficially it is not a particularly attractive option, to be honest, because we would simply be removing from all the various settings where the question of obesity currently appears and in a sense possibly remove it from the gaze of those who are working on some of the key areas that would make a contribution. On things like coronary heart disease and diabetes we may actually be taking it away from those areas rather than actually creating—as I know you would want to do through this—a stronger focus. The question is what would get a stronger focus? I would argue that a good understanding of how these things go together within a clear framework where it is clear what the contributions of different frameworks—the NSFs and the other standards that we have produced—are to that, together with various other incentivisations at health services level (like the ones that we have through the new GMS contract and developing the existing services that we have under the present arrangements) are the sorts of things that will drive this agenda forward first in terms of health service focus.

  Q1334 John Austin: You mentioned equalities in an earlier answer. We have very clear evidence that many minority ethnic groups are at higher risk at much lower levels of overweightness or lower BMIs. Does the Department have any targeted programmes to get into those communities to tackle the issue which I think is particularly a problem in some of the Asian communities?

  Miss Johnson: That is certainly correct. There are particular problems for particular sections of the population who may be more at risk than others. I went on a visit to Waltham Forest relatively recently where, indeed, they are focussing on some of their ethnic minority populations who are particularly at risk of diabetes. I think the answer, as with a lot of the health inequalities in public health issues, is to actually enable and make sure that at a fairly local level the PCTs, the public health people and the services are focussed on access and improving the health of their own particular populations and the breakdown of those populations in terms of different groups, and actually recognising the different issues that may give them in the balance that they ought to be focussing on on things like diabetes (it is true on a number of other areas too). Therefore we can get significant improvements from that fairly localised focus and that is indeed what is happening already in many parts of the country.

  Q1335 John Austin: If the Department has any examples of effective community projects which are tackling that, I think it would be extremely useful.

  Miss Johnson: I will write to you with some examples. In terms of the diabetes, the current cost is 1.3 billion, but I think you were asking for the future cost and we will see what figures we have in the Department on that.

  Q1336 Dr Naysmith: Minister, you have already said this morning that the role of other government departments is crucial in tackling obesity. I agree with that; who could not? One important area must be a measure of coherence in working together and the avoidance of giving mixed messages. The United Kingdom Public Health Association and the Food Standards Agency have both criticised support of schemes that link less healthy foods with sport. Some have told us in evidence at this Committee that the promotion of unhealthy foods is particularly obnoxious when linked to an endorsement by high profile media personalities. The Sports Minister, Richard Caborn, strongly endorsed the Cadbury GetActive campaign and the Department for Education and Skills endorsed a scheme where purchases of Walkers Crisps contribute towards purchasing school equipment. We were told by your officials that they did not know about these, they were not consulted about these campaigns before they were endorsed by other departments. It would not be unreasonable to imply that this does not demonstrate joined up government very well.

  Miss Johnson: I think it was not a happy set of circumstances that led to that. It was before my time in this post so I cannot comment on the detail of it, but it was not a government programme and these programmes that you are talking about were not government endorsed. I am sure that is not something that is necessarily going to be repeated in the future.

  Q1337 Dr Naysmith: It is a fact that the quote from Richard Caborn endorsing the campaign is still available currently on the GetActive website. I do not know whether it is possible to act retrospectively and do something about that.

  Miss Johnson: I am sure you are seeing the Department for Culture, Media and Sport; I think you are seeing Tessa Jowell at some point before too much longer and I am sure that is something you will want to raise.

  Q1338 John Austin: In the interest of joined up government would you have a message for the Minister of Sport?

  Miss Johnson: Not in this environment.

  Q1339 Mr Burns: Are you saying you did endorse the campaign?

  Miss Johnson: It was not a government endorsement, no.


 
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